This link will leave wellcare.com, opening in a new window. WellCare and its subsidiaries are not responsible for non-WellCare content, privacy practices, products or services described on these websites.
Supervises a team of Appeals Review Nurses in the day-to-day workflow processes of the Provider and/or Member Appeal functions.
Reports to: Sr.Dir. Appeals & Retro Review
Department: HS-Appeals & Retro Review
Location: Tampa, FL.
Utilizes clinical knowledge to apply information to WellCare's designated criteria in order to make authorization decisions and assist the Medical Director with appeal determinations.
Reviews information provided by Appeal Review Nurses concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process.
Troubleshoots more complex cases elevated by nurses. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action within the appeal process.
Monitors associate performance for timely and accurate processing of appeals, attendance, schedules, and other job related behavior. Ensures the collection, interpretation and safekeeping of all materials concerning each appeal.
Reviews appeal management and error reports to ensure associate productivity, accuracy and timeliness. Gives subordinates regular feedback on performance and conducts counseling/corrective action procedures, up to and including separation, with manager and HR oversight when needed.
Writes midyear and annual performance evaluations and reviews with associates.
Completes new hire requisitions, conducts interviews and makes hiring decisions for associates in work group. Ensures comprehensive training for each new hire, including intensive period of supervision for first 90-120 days.
Receives routine and ad hoc audit results from Appeal Auditors and routinely delivers results to subordinates. Identifies & coordinates additional team member training needs based on associate performance.
Answers internal and external customer questions, assists peers and Manager, Sr. Manager or Director with tasks. Serves as first line contact for the company's problem resolution procedure for associates in his/her work group. Serves as liaison for escalated appeal issues identified by the Provider Relations team..
Plays active role in creating, applying and utilizing accepted policies and procedures to review process and utilizes the parameters.
Monitors decisions made by Appeals Review Nurses to ensure correct application of criteria utilized in making clinical decisions not involving a Medical Director and ensures appropriate use of admission authorizations.
Attends company meetings in absence of Manager, Sr. Manager or Director. Frequently serves on cross-functional WellCare workgroups as Appeals (or Health Services) representative.
Maintains a routine limited caseload and when necessary provides additional coverage to maintain compliance and to cover work group for PTO or medical leave.
Makes recommendations and leads process improvement as needs are identified.
Reviews appeal outcome reports that identify numbers, trends or patterns in the appeals process and reports findings to manager, director, other departments, and any committees as necessary.
Performs other duties as assigned.
Required A High School or GED
Preferred An Associate's Degree in a related field nursing
Required 4 years of experience in A clinical or managed care setting with exposure to pre-authorization, utilization review, concurrent review, and/or discharge planning.
Required 1 year experience in leading/supervising others In a clinical or managed care setting (preferred) where you functioned in a team lead or senior capacity, providing mentoring, training, support, and guidance and functioned as a subject matter expert (SME)
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Knowledge of community, state and federal laws and resources Knowledge of community, state and federal laws and resources
Intermediate Ability to effectively present information and respond to questions from families, members, and providers Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to lead/manage others in a matrixed environment
Intermediate Other Knowledge of Utilization Management principles and criteria sets such as InterQual, Medicare guidelines,etc
Intermediate Other Strong clinical knowledge on broad range of medical practice specialties
Licenses and Certifications: A license in one of the following is required:
Required Licensed Practical Nurse (LPN)
Preferred Licensed Registered Nurse (RN)
Preferred Intermediate Microsoft PowerPoint Proficient in Microsoft Outlook applications, including Word, Excel, PowerPoint and Outlook
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Word Ability to use proprietary health care management system
Required Intermediate Microsoft Outlook
Required Intermediate Healthcare Management Systems (Generic)